Test 1 Flashcards

Question

Do white men or black women have longer life expectancy?

Answer 1

Black women

Answer 2

The systematic stereotyping of and discrimination against people because they are old

Answer 3

Problems that are typically multifactorial in etiology and that therefore are rare in younger persons and common in the elderly.

Answer 4

Frailty, weakness, dizziness, confusion, gait problems, falls, and incontinence

Answer 5

Slow medicine describes a philosophy and approach that applies the principle of beneficence (first do no harm) The best ARNP is not the one who makes the most diagnoses, its the one who identifies and addresses the patients most important functional problems

Answer 6

Intellectual impairment Immobility Instability Incontinence Iatrogenic disorders

Answer 7

Decreased muscle mass Decreased water Increased deep fat in elderly

Answer 8

Older person thinks it is part of aging Older person is embarrassed to report the issue Older person is not aware he/she has a problem

Answer 9

Functional Status: Answer yes to one of the following: Because of a health problem, do you need help to: Shop? Do light house work? Walk across a room? Take a bath: Manage household finances? IADLs Access all other ADLs for self-care (bathing, toileting, dressing, transfer bed to chair, grooming, feeding) Instrumental: (use telephone, prep meals, manage finances, take meds, doing laundry, housework, shopping manage transportation) Mobility: (walking inside/outside, climbing stairs, the Katz index tool)

Answer 10

“Time up and go” test: unable to complete in <16 seconds Asses: Comprehensive M/S and neuro assessment. Manage: Treat underlying M/s and neuro assessment Refer to PT

Answer 11

Unintentional weight loss of ≥ 5% in prior 6 months or BMI < 20kg/m2) Asses: Mini Nutritional Assessment for older adults Manage: Oral supplements, meals on wheel, appetite stimulant.

Answer 12

Unable to read newspaper headline while wearing corrective lenses, unable to read greater than 20/40 Assess: Screen for common eye diseases of older patient: (cataracts, macular degeneration, glaucoma, diabetic retinopathy. Manage: Refer to eye doctor

Answer 13

Acknowledge hearing loss when questioned or failed the whispered test at a distant of 2 feet Assess: Comprehensive HEENT exam Rinne/weber test Conductive/obstructive hearing loss r/v med (Lasix, salicylates cause reversible hearing loss) Manage: Refer to audiologist

Answer 14

3 item recall: Unable to remember all 3 items after 1 minute Assess: Administer Mini Cog or MMSE Assessment for co-morbidities (infections, stroke, nutritional deficiencies and manage accordingly)

Answer 15

PHQ2: Answer yes to either of the following: In the past 2 weeks have you often be bothered by: Feeling down, depressed or hopeless? Having little interest or pleasure in doing things? Assess: PHQ-9 or Geriatric depression scale R/o other illnesses such as hypothyroidism, anemia, Vit d deficiency, recent loss, Manage: Medication for depression Refer for counselling.

Answer 16

1. Intellectual impairment 2. Immobility 3. Instability 4. Incontinence 5. Iatrogenic disorders

Answer 17

1.Focuses on elderly individuals with complex problems, 2.Emphasizes functional status and quality of life 3.Takes advantage of an interdisciplinary team of providers 4. Five I's of geriatrics

Answer 18

A low BMI (less than 20 kg/m2) is a risk factor for falls in older adults. Having a normal weight (BMI 18.5-24.9) or being overweight (BMI 25.0-29.9) may decrease mortality in older adults. Additional risk factors for falls include age older than 80 years old, female gender, previous falls, balance or gait impairment, decreased upper or lower muscle strength, visual impairment, medications (more than 4 total meds or use of psychoactive med use), depression, dizziness or orthostasis, functional limitations, urinary incontinence, cognitive impairment, arthritis, diabetes, and pain.

Answer 19

Age older than 80 years old Female Lower body mass index (BMI) less than 20 Previous falls Balance or gait impairment Decreased upper or lower muscle strength Visual impairment Medications (more than 4 total meds or use of psychoactive med use) Depression Dizziness or orthostasis Functional limitations Urinary incontinence Cognitive impairment Arthritis Diabetes Pain

Answer 20

Visual acuity worse than 20/40 - Visual acuity of worse than 20/40 suggests weakness in the ability to see. Abnormality in the six cardinal fields of gaze - Abnormality in cardinal fields of gaze may indicate a neurological condition. Confrontation test with deficit R>L - Abnormal Confrontation test= deficit in the peripheral visual field, indicative of glaucoma.

Answer 21

1. Basic self-care. 2. Mobility. 3. Continence.

Answer 22

Elimination of drugs

Answer 23

Drug absorption Drug absorption is affected when gastric acidity declines with age because of decreased intestinal blood flow and fewer absorbing cells in the gastrointestinal (GI) tract. It is also affected with the presence of food and other drugs in the stomach at the same time.

Answer 24

CHECK FOR ALLERGIES TO MEDS AT EVERY VISIT. *With each encounter, Update and reconcile the medication list *Brown paper bag check at least annually *Update pharmacy info if needed *Check for the need for refills *Reviewing medications: check about adherence and cognitive abilities (at least annually) *Discuss method of medication administration (at least annually) and address if simplification (Extended release meds, combo meds) might help adherence. *Scrutinize for problem medications: *Not appropriate for the elderly *Requiring lab follow up

Answer 25

At least annually ask patient to bring all his medications ( prescribed, OTC, herbals, supplements) to the office

Answer 26

HCP should consider any new symptoms in the elderly as a drug side effect until proven otherwise

Answer 27

Creating an individualized plan 1.Patient life’s expectancy 2.Time till benefit from medication 3.Goal of care 4.Treatment targets -Symptom-targeted approach -Disease modifying approach

Answer 28

Beneficence and patient's autonomy First do no harm!

Answer 29

Consider any new sign and/or symptom in the elderly as a drug side effect until proven otherwise START LOW AND GO SLOW Try not to start two medications the same time Search for one medication that might treat two diseases at the same time. Administration time: Same as the other medication to increase adherence Use of long acting meds if patient can afford the higher co-pay. Assess patient and/or care giver knowledge regarding med.

Answer 30

-Uses the correct drug -Prescribes the correct dosage -Targets the correct condition -Is appropriate for the patient Failure in any one of these can result in adverse drug events (ADEs)

Answer 31

The Beers Criteria, defined inappropriate prescribing of medication as those drugs whose risks outweigh the benefits, namely as it relates to the geriatric population.

Answer 32

Some of the weak areas of the Beers Criteria

Answer 33

The STOPP/START Criteria were developed to determine when medications should be added and when another might be discontinued for an older patient.

Answer 34

1. The Beers Criteria 2. Medication Appropriateness Index 3. STOPP/START Criteria

Answer 35

STOPP/START criteria The Screening Tool of Older Person's Prescriptions (STOPP) criteria and the Screening tool to alert doctors to right treatment (START) ---Both screening tools are intended to be used together ---Help prevent inappropriate polypharmacy and prescribing -> reduction of ADE ---More thorough than BEERS, as it includes drug-drug interaction, and potential duplications ---Identify inappropriate prescribing, was introduced in 2008 and updated in 2015 STOPP: Include a list of PIMs (Potentially inappropriate medications) START: Include PPOs (potential prescribing omissions)

Answer 36

Detect prescribing of P I M’s (prescribing inappropriate medications)

Answer 37

Inappropriate medications to be avoided in older adults

Answer 38

STOPP/START criteria The Screening Tool of Older Person's Prescriptions (STOPP) criteria and the Screening tool to alert doctors to right treatment (START) * Both screening tools are intended to be used together * Help prevent inappropriate polypharmacy and prescribing -> reduction of ADE * More thorough than BEERS, as it includes drug-drug interaction, and potential duplications * Identify inappropriate prescribing, was introduced in 2008 and updated in 2015

Answer 39

Include a list of PIMs (Potentially inappropriate medications)

Answer 40

Include PPOs (potential prescribing omissions)

Answer 41

START CVS, Respiratory, CNS

Answer 42

When the side effects from one drug causes a new illness that has to be treated with another drug and then that process continues

Answer 43

* Accurate medication reconciliation at each visit * Always consider s/s as a potential drug adverse event and ID patient at high risk * Define overall care goals in the context of life expectancy * Awareness of the drug cost and other barriers to improve compliance * Awareness of pharmacokinetics changes with aging * Estimate the benefits vs harm in relation to each new medication * Use of behavioral modifications and nonpharmaceutical approach to treat new conditions * Keep up to date with guidelines

Answer 44

Medicare only covers tests that are approved according to the stringent guidelines of the U.S. Preventive Services Task Force (USPSTF). * Grade A and B are covered by Medicare and on rare occasion with good documentation Grade C.

Answer 45

UPSTF recommends against screening on asymptomatic patient (grade D) With this test Asymptomatic bacteriuria - Urinalysis Coronary artery disease - ECG, Treadmill test, or electron beam CT Carotid artery stenosis - Duplex U/S COPD - spirometry Pancreatic cancer - U/s, abdominal palpation, or serologic markers

Answer 46

1. Preventing the occurrence of a disease or condition.

Answer 47

Primary preventive strategies focus on immunization, well-checks, and other health maintenance activities. It is viewed as the most effective form of health care

Answer 48

Secondary preventive strategies focus on screening, and detection of diseases before symptoms appear

Answer 49

Tertiary preventive strategies focus on rehabilitation management of existing conditions .

Answer 50

Nurse practitioners focus on the wellness–illness continuum.

Answer 51

1. Preventing the occurrence of a disease or condition.

Answer 52

1- Primary

Answer 53

Tertiary prevention

Answer 54

Tertiary prevention aims to soften the impact of an ongoing illness or injury that has lasting effects. This is done by helping people manage long-term, often-complex health problems and injuries (e.g. chronic diseases, permanent impairments) in order to improve as much as possible their ability to function, their quality of life and their life expectancy. Examples include: cardiac or stroke rehabilitation programs, chronic disease management programs (e.g. for diabetes, arthritis, depression, etc.) support groups that allow members to share strategies for living well vocational rehabilitation programs to retrain workers for new jobs when they have recovered as much as possible.

Answer 55

≥ 5 years of remaining life expectancy: Robust Less than 5 years of remaining life expectancy and/or moderate dementia (2- 10 years of remaining : Frail End of Life: <2 years of remaining life expectancy Hospice < 6 months of remaining life expectancy to be eligible

Answer 56

BTW the Task force recommend against self breast examination for all women. USPSTF recommend biennial screening mammography for women aged 50 to 74. So IF Simone was robust with life expectancy above 5 years, she should get screened Remember, it is not recommended, if after conversation with the patient she wants it, well you should order it . Respect for autonomy is key, but let’s say she was due for a colonoscopy, GI doctor might not want to put her under due to her frailty. And screen with FIT instead.

Answer 57

The USPSTF recommend against PSA based screening for prostate cancer in asymptomatic males over the age 70.

Answer 58

“Let discuss your concerns first, then I let you know about the procedures risk and benefits, and we can decide to go ahead or not with the test”

Answer 59

What is her ppk/year history. 40 pack/year How would you report it in your SOAP note. 40 pack/year. Quit 2011

Answer 60

1- No, she smoke less than 20 cigarettes and quit more than 5 years ago **2- Yes, she should be screened for the next 5 years with low dose CT** 3- yes, all smokers regardless of ppk/year should be screen till they are 70 year old 4- NO, she is not a smoker anymore. She quits, her risks are back to normal.

Answer 61

Neither now or in the future Task force recommendations: 21 to 65 yo every 3 years. So if she had a total hysterectomy due to GU cancer, you will continue with the recommendation as if she still had a cervix. And stop as recommended Adequate screening = Three consecutive negative cytology results or 2 consecutive negative HPV results within 10 years before cessation of screening, with the most recent test within 5 years

Answer 62

45 YEAR OLD

Answer 63

Screening Tests for Colorectal Cancer Stool Based Tests: Bowel prep and anesthesia not required Please note Stool based tests are not a replacement for direct visualization tests: Colonoscopy, Sigmoidoscopy. High level of false positive which lead to unnecessary colonoscopy. High sensitivity gFOBT: Every year (not the old hemoccult II) FIT: Every year. SDNA-FIT (Cologuard): Every 1 or 3 years

Answer 64

Direct visualization test: colonoscopy every 10 years Sigmoidoscopy every 5 years or Sigmoidoscopy every 10 years plus FIT every year CT colonography every 5 years Colon capsule: USPSTF no recommendation.: More research needed. USPTSTF and American College of Gastroenterology recommend colonoscopy and FIT as the primary screening modalities for CRC screening. Please note: For patients unwilling or unable to undergo colonoscopy (Make sure you chart accurately) you may consider Stool screening tests, CT Colonoscopy or Colon capsule. Please chart got chart. (ACG, 2021)

Answer 65

Atleast annually

Answer 66

Adults over age 65 who are healthy and do not take medications should not have more than: 3 drinks on a given day 7 drinks in a week total (So about one drink daily) Older adults are at risk for serious alcohol problems who drink more then recommended amount (NIH, 2018)

Answer 67

American Geriatrics Society (AGS) has defined high-risk drinking as more than 3 drinks on heavier drinking occasions or more than 7 drinks per week for adults 65 and older

Answer 68

Geriatric Lab Values & Interpretations of Hematology

Answer 69

GFR and Chronic Kidney Disease

Answer 70

Thyroid Fuction Tests

Answer 71

Metabolic syndrome * Atleast three of the risk factors to be diagnosed with metabolic syndrome: * A large waistline, which means a waist measurement of * 35 inches or more for women * 40 inches or more for men * A high triglyceride level, which is 150 mg/dL or higher * A low HDL cholesterol level, which is * Less than 50 mg/dL for women * Less than 40 mg/dL for men * High blood pressure, which is a reading of 130/85 mmHg or higher. * A high fasting blood sugar, which is 100 mg/dL or higher

Answer 72

First, there is a reduced physiological reserve of most body systems, particularly the cardiac, respiratory, and renal systems. Second, there are reduced homeostatic mechanisms that fail to adjust regulatory systems such as temperature control and fluid and electrolyte balance. Third, there are the changes in the sympathetic response, which contribute to orthostasis and falls, as well as lack of hypoglycemic response. Fourth, there is impaired immunological function: infection risk is greater and autoimmune diseases are more prevalent.

Answer 73

Exercise intolerance in a CHF patient

Answer 74

Shortness of breath on exertion in a sedentary older person

Answer 75

Arthritis knee in a former football player

Answer 76

Difficulties reading fine print

Answer 77

1. If problem is a disease -> medical treatment 1. If problem is disuse -> Behavioral management 1. If problem is misuse -> Prevent deterioration and preserve function 1. If problem is physiologic aging -> assist with adaptation, and compensation for the disability

Answer 78

Physiologic reserve – Definition The remaining capacity of an organ or body part to fulfil its physiological activity; (especially) in the context of stress, disease, ageing, or impairment. Significant impairment from disease, disuse, misuse or physiologic aging result impaired functional reserve

Answer 79

What does depletion of physiologic reserve lead to

Answer 80

* Difficult to maintain a balanced physiologic environment. * Delayed return to homeostatic state * Impairment worsened during time of stress.

Answer 81

* Decreases ability to adapt to stress. * More susceptible to disease

Answer 82

Presbycuccis: Loss of high frequency sounds starting at 55 yo.

Answer 83

* Cardiac functions no change at rest with normal CO and HR * Cardiac reserve declines compromising ability to respond to stress -> decreased activity tolerance * Baroreceptors (which stabilize blood pressure with activity) are less sensitive as one ages, which can lead to orthostatic hypotension. Heart valve sclerosis * Increased vascular vessels thickness and stiffness -> diminished vessel compliance and greater systemic vascular resistance ->elevated systolic with constant diastolic

Answer 84

* Muscle strength and endurance deteriorate -> Less effective inspiration and expiration * Decreased elasticity of lungs tissues and loss of elastic recoil, increased chest wall rigidity -> decreased vital capacity. * Skeletal changes -> barrel chest -> increased residual volume * Decreased number of alveoli-> decrease in oxygenation to the vital organs * Decreased cilia, macrophages, cough reflex -> risk of infections, bronchospasms and obstruction

Answer 85

As people age they become more diverse. This explains why individualized care rather than protocol-based care is especially important in the geriatric population.

Answer 86

Low self esteem, isolation, reduced opportunities and depression

Answer 87

* Withhelding care * Lack of knowledge regarding the rule of fourths * Physiologic changes equal 25% not the majority of the decline in function. * Overmedications instead of non pharmaceutical approaches * Time management: it takes longer to care for an elderly patients with multiple comorbidities, and diseases, but everyone get their 15 minutes or less. -> misdiagnoses

Answer 88

* The HCP should ID functional deficits adversely affecting patient prognosis and quality of life * Can we do something about it -> Medical intervention * ID what can not be improved with medical treatment -> Rehab, social support and yes empathy. * The best ARNP is not the one who makes the most diagnoses, it’s the one who identifies and addresses the patient’s most important functional problems.

Answer 89

Illness cause by US. (medical providers)

Answer 90

Most iatrogenic disorders can be avoided by using simple precautions, ie, increased knowledge of contraindications, restriction of self-medication, and lowering the number of concomitant drugs. Slow medicne, start low and go slow

Answer 91

The remaining capacity of an organ or body part to fulfil its physiological activity; (especially) in the context of stress, disease, ageing, or impairment.

Answer 92

Palliative care is a service offered by many hospice agencies to provide symptom management and comfort care to patients who may not have a terminal diagnosis, cannot be certified as having a life expectancy of less than 6 months, or do not want to sign a DNR or forgo other life-sustaining or curative treatments (such as a patient with cancer who wants to continue to receive chemotherapy but is having pain, nausea, or shortness of breath that is poorly controlled).

Answer 93

Palliative care plays an important role in enhancing patient's quality of life by improving their ability to achieve personalized goals, such as symptom control and social support, while setting realistic expectations through impeccable communication

Answer 94

End-of-life symptoms commonly include pain, delirium, dyspnea, nausea and vomiting, constipation, noisy secretions, cough, and fever

Answer 95

SPIKES is an acronym for presenting distressing information in an organized manner to patients and families. The SPIKES protocol provides a step-wise framework for difficult discussions such as when cancer recurs or when palliative or hospice care is indicated.

Answer 96

It is important to consider the effect of preventive health measures not only on quantity of life but also on quality of life, satisfaction with life, and in maintaining independence Preventive health recommendations for older adults need to be individualized based on patient health, function, risk of disease, and preferences

Answer 97

Breast cancer screening Cervical cancer screening Colorectal cancer screening People who have smoked or do smoke should discuss lung cancer screening Prostate cancer screening Osteoporosis Abdominal aneurysm

Answer 98

Breast Cancer Breast Exam: * Self breast exam : Not recommended (grade D) * Clinical breast exam (CBE): Insufficient evidence (grade I) * ACS ( American Cancer Society) recommend that all women should be familiar with their normal breast tissue and report any changes to their HCP. * USPSTF B: Women with a person or fam hx of breast, ovarian, tubal, or peritoneal ca or an ancestry assoc with BRCA1/2 gene mutation * USPSTF D: No routine testing for BRCA1/2

Answer 99

Screening frailed patient: Choosing Wisely® = not to recommend breast cancer screening to older women without considering their life expectancy, because women with < 10 years of remaining life expectancy are exposed to immediate harms of screening with little chance of benefit

Answer 100

**USPTSF A** Women aged 21 to 65 years * 21 - 29yo Screen for cervical ca every 3 years * 30 - 65yo Screen for cervical ca every 3 years with cytology alone every 5 years for for hrHPV alone or q 5 years with cotesting **USPTSF D ** * for women <21yo * hx or hysterectomy with rem of cervix and no hx of cervical ca or precancerous lesions * women > 65yo with adequate prior screening and no risk of cervical ca

Answer 101

Screening includes: High sensitivity guaiac fecal occult blood test or fecal immunochemical test every year Stool DNA- Fit 1-3 years C/T every 5 years Flex sig every 5 years Flex sig every 10 years + annual FIT Colonoscopy every 10 years

Answer 102

Screening for prostate ca begins with PSA. Elevated PSA can be caused by BPH, prostatis (inflammation) or ejaculation. USPSTF does not recommend DRE for screening only in men with elevated PSA as secondary test

Answer 103

* Age 50 for men who are at average risk of prostate cancer and are expected to live at least 10 more years. * Age 45 for men at high risk of developing prostate cancer. This includes African Americans and men who have a first-degree relative (father or brother) diagnosed with prostate cancer at an early age (younger than age 65). * Age 40 for men at even higher risk (those with more than one first-degree relative who had prostate cancer at an early age).

Answer 104

* Men who choose to be tested who have a PSA of less than 2.5 ng/mL may only need to be retested every 2 years. * Screening should be done yearly for men whose PSA level is 2.5 ng/mL or higher. * men without symptoms of prostate cancer who do not have a 10-year life expectancy should not be offered testing

Answer 105

0-2.5: Normal PSA for a man 40-50 yrs. 2.5-3.5: Normal PSA for a man 50-60 yrs. 3.5-4.5: Normal PSA for a man 60-70 yrs. 4.5-5.5: Normal PSA for a man 70-80 yrs.

Answer 106

* BPH * Older age * Prostatitis * Ejaculations (When you order PSA strongly suggest no ejaculation a day or two before test) * Riding a bicycle ( no riding a day prior to test) * Urologic procedures (including DRE) * Medications: Testosterone replacement.

Answer 107

* Screen every year with a low dose CT * Stop screening once a person has not smoked for 15 years or has a health problem that limits life expetancy or the ability to have lung surgery * Stop screening at 80yo regardless of history

Answer 108

Adults 50 to 80 who have 20 pack year smoking hx and currently smoke or quit within last 15 years

Answer 109

Evidence lacking regarding optimal interval if Screening result is unremarkable The National Osteoporosis Foundation recommends assessing BMD every 2 years And more often if Osteoporosis is present.

Answer 110

Evidence lacking regarding optimal interval if Screening result is unremarkable The National Osteoporosis Foundation recommends assessing BMD every 2 years And more often if Osteoporosis is present.

Answer 111

Considering clinical condition and personal habits, counsel older adults about: * Physical activity— at least annually * Nutrition – obtain weight at each visit and height annually to calculate BMI * Alcohol misuse—initially, then if symptomatic * Smoking cessation—every visit * Sexual dysfunction and sexually transmitted infections—routinely

Answer 112

* Moderate-intensity aerobic activity; minimum: 30 min 5 days/wk, or * Vigorous-intensity aerobic activity; minimum: 20 min on 3 days each week

Answer 113

8–10 exercises ≥2 nonconsecutive days/wk using the major muscle groups

Answer 114

Flexibility exercises on ≥2 days/wk for at least 10 min each day

Answer 115

Exercises that maintain or improve balance (recommended for community-dwelling older adults with substantial risk of falls)

Answer 116

Flu double strength Pneumoccal (1 dose PCV15 followed by PPSV23 1 year later OR 1 dose PCV20) Hepatitis B Herpes Zoster 2 doses Tdap the Td or Tdap booster every 10 years

Answer 117

* Screen all adults 18 years or older for ETOH misuse (Grade B) * Provide behavioral counseling to reduce ETOH misuse (grade B) * Ask all older adults ≥ 65 years old at minimum annually about their alcohol use

Answer 118

* 3 drinks on a given day * 7 drinks in a week total (So about one drink daily) * Older adults are at risk for serious alcohol problems who drink more then recommended amount (NIH, 2018)

Answer 119

*AUDIT, AUDIT-C, or single-question screening (e.g., “In the past year, have you had four or more drinks in 24 hours?”)

Answer 120

1. How often do you have a drink containing alcohol? 2. How many drinks containing alcohol do you have on a typical day when you are drinking? 3. How often do you have 6 or more drinks on one occasion?

Answer 121

* USPSTF: Ask all adults about tobacco use and provide behavioral interventions and approved pharmacotherapy for cessation. (grade A) * report it in ppk/year

Answer 122

Five major steps to intervention are the "5 A's": Ask, Advise, Assess, Assist, and Arrange. * Ask about tobacco use at every visit, * Advise to quit, * Assess willingness to quit * Assist : behavioral modification and pharmacotherapy * Arrange: designate a quit date, and provide close medical follow-up in person or over the phone routinely for next 3 months.

Answer 123

It is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked. For example, 1 pack year is equal to smoking 1 pack per day for 1 year, or 2 packs per day for half a year, and so on.

Answer 124

Check smoke detectors and carbon monoxide detectors, check water heater temperature, use sun protection, assess driving skills, wear seat belts, complete advance directives and determine health care proxy

Answer 125

Question with clinical suspension

Answer 126

an inability to maintain or regain homeostasis effectively causing a cumulative decline across multiple systems of functioning

Answer 127

Therefore, an increased vulnerability to disease

Answer 128

* Consider the physical space * Determine a suitable environment * Pay attention to privacy, comfort, and quiet * Ensure all equipment is available and in working order * Introduce yourself * Address the patient by last name * Face the patient directly * Sit at eye level * Speak slowly * And yes do start with open-ended questions: Take into account potential low health literacy.

Answer 129

1. Inquire about hearing deficits; raise voice volume accordingly 2. If necessary, write questions in large print 3. Allow ample time for patient to answer

Answer 130

Five I’s of geriatrics 1. Intellectual impairment 2. Immobility 3. Instability 4. Incontinence 5. Iatrogenic disorders

Answer 131

1. Focuses on elderly individuals with complex problems, 2. Emphasizes functional status and quality of life 3. Takes advantage of an interdisciplinary team of providers. and the five I's

Answer 132

Goal: Promote wellness, independence Focus: Function, performance (gait, balance, transfers) Scope: Physical, cognitive, psychologic, social domains Approach: Multidisciplinary Efficiency: Ability to perform rapid screens to identify target areas Success: Maintaining or improving quality of life

Answer 133

Geriatric assessment is a multifaceted approach to the care of older adults, wit the goal of promoting wellness and independent function

Answer 134

Incorporate into routine office visit: * 1- Rapid screening of targeted areas followed by comprehensive assessment in area of concerns * Rapid screening of targeted areas * Completed by trained office staff (MA, LPN) * Completed by patient/surrogates at home or office * 2- Rolling Assessment * Target one area for screening with each office visit.

Answer 135

Answer yes to one of the foll0wing to assess IADLs: Because of a health problem, do you need help to: Shop? Do light housework? Walk across a room? Take a bath or shower? Manage household finances? Assessment and Management Assess all other ADLs for: self care (bathing, toileting, Dressing, transfer bed to chair, grooming, feeding) Instrumental (use telephone, prep meals, manage finances, take meds, doing laundry, housework, shopping, manage transportation) Mobility: (walking inside/outside, climbing stairs, The Katz index tool.

Answer 136

“Time up and go” test: unable to complete in <16 seconds Assessment and Management Comprehensive M/S and neuro assessment. Treat underlying M/s and neuro assessment Refer to PT

Answer 137

Unintentional weight loss of ≥ 5% in prior 6 months or BMI < 20kg/m2) Assessment and Management * Mini Nutritional Assessment for older adults * Oral supplements, meals on wheel, appetite stimulant.

Answer 138

Unable to read newspaper headline while wearing corrective lenses, unable to read greater than 20/40 Assessment and Management * Screen for common eye diseases of older patient: (cataracts, macular degeneration, glaucoma, diabetic retinopathy. * Refer to eye doctor

Answer 139

Acknowledge hearing loss when questioned or failed the whispered test at a distant of 2 feet Assessment and Management * Comprehensive HEENT exam * Rinne/weber test * Conductive/obstructive hearing loss * r/v med (lasix, salicylates cause reversible hearing loss) * Refer to audiologist

Answer 140

Answer yes to either of the following: In the past 2 weeks have you often be bothered by: Feeling down, depressed or hopeless? Having little interest or pleasure in doing things? Assessment and Management * PHQ-9 or Geriatric depression scale * R/o other illnesses such as hypothyroidism, anemia, Vit d deficiency, recent loss, * Medication for depression * Refer for counselling.

Answer 141

* Visual inspection * Rapid screen test: * Unintentional weight loss of ≥ 5% in prior 6 months or BMI < 20kg/m2) If positive * Mini-nutritional assessment for older adults (MMA) * Comprehensive Physical assessment * Laboratory tests -Serum albumin to help determine protein and immune status. -Serum cholesterol and homocysteine to determine risk level for CVD. Levels below 160 may indicate gastrointestinal problems.) -Blood glucose in diabetics and periodically in non-diabetic elders since glucose intolerance increases with aging. -Hemoglobin/hematocrit to evaluate for anemia, a prevalent condition in the elderly. -Vitamin B12 (especially in vegans, with indications of achlorhydria and gastrointestinal problems).

Answer 142

wellness and independence

Answer 143

communication

Answer 144

A comprehensive assessment includes physical, cognitive, psychological, and social aspects of health

Answer 145

Two methods: Self report see previous slides and performance: Timed Get Up and Go test: Qualitative; timed; assesses gait, balance, and transfers Sensory capacity ---Read from a newspaper ---Whisper test Gait speed ---Strongest predictor of future disability and death Balance: ---Sharpened Romberg test: Test balance: feet together/semi tandem

Answer 146

Cognitive Assessment Psychologic Assessment Spiritual Wellbeing

Answer 147

* Perception, memory, and thinking * The processes by which a person: * Perceives information * Recognizes information * Registers information * Stores information * Uses information

Answer 148

Most people with dementia do not complain of memory loss Cognitively impaired older persons are at  risk for accidents, delirium, medical nonadherence, and disability Prevalence of cognitive decline Doubles every 5 yr after age 65 Nearly 50% of those aged 90

Answer 149

* Report screening results with the appropriate context in which these were obtained * Avoid assessment periods: * Immediately on awakening from sleep (wait at least 30 minutes) * Immediately before and after meals * Immediately before and after medical procedures

Answer 150

1. Always obtain a baseline 2. Benchmark subsequent results with baseline

Answer 151

Folstein's Mini Mental State Examination (MMSE) The Montreal Cognitive Assessment (MOCA)

Answer 152

Assesses orientation, attention, memory, concentration, language and constructional ability

Answer 153

Assesses: attention and concentration, executive functions, memory, language, vosuoconstructional skills, conceptual thinking, calculations and orientation

Answer 154

* Ask, “Do you often feel sad or depressed?” * If patient responds affirmatively do further evaluation, eg, Geriatric Depression Scale or PHQ-9 * Other short instrument : Geriatric Depression Scale (short or long form) * Watch for signs of anxiety, bereavement: if suspect: administer GAD-7

Answer 155

* Prescribing many drugs with long term use * Prescribing five or more drugs with long term use (90 days or above) * Prescribing potentially inappropriate medications (P I M’s) * Underprescribing, overprescribing, and misprescribing, duplication

Answer 156

Absorption Distribution Metabolism Elimination

Answer 157

**Absorption is the least pharmacokinetic factor impacted by aging** * Reduced stomach acidity * Decreased absorption of calcium carbonate and antifungal po * Decreased gastric motility * Reduced drug absorption in the small intestine * Decreased First pass metabolism

Answer 158

Age-associated changes in body composition can alter drug distribution  body water  lower VD for hydrophilic drugs  lean body mass  lower VD for drugs that bind to muscle  fat stores  higher VD for lipophilic drugs  plasma protein (albumin)  higher percentage of drug that is unbound (active)

Answer 159

Definition: A medication’s distribution describes the extent to which a drug passes into different body compartments

Answer 160

Two phases: * Phase 1 Metabolism: * Cytochrome P450: reduction and oxidation of the drug * Age related decline in phase one due to reduction of hepatic perfusion and liver size and mass (varied greatly among people, due to genetic confounder) * Decrease first pass metabolism * Lead to increased half-life * Phase 2 metabolism: Hepatic conjugation of the drug to make substance inactive and facilitate excretion * Phase 2 is usually not affected by normal aging changes

Answer 161

overall intake of a drug is fairly in dynamic equilibrium with its elimination. Reach usually after 5 half-lives

Answer 162

Elimination: via * Most drugs are excreted the kidneys * Rate of elimination is influenced by * Glomerular filtration * Tubular secretion * Reasorption

Answer 163

* With aging: * kidney size * renal blood flow * number of functioning nephrons * renal tubular secretion * Aging, common geriatric disorders, polypharmacy can impair kidney functions * Reduced elimination  potential drug accumulation and toxicity * GFR and tubular function declines with aging

Answer 164

Effects of the drugs on the body and mechanisms of their action

Answer 165

Pharmacodynamics in aging: limited data * Might be related to change in receptor affinity or number. * Older adults have higher sensitivity to benzodiazepines and other central nervous depressors such as opiods, and anticoagulant effect of heparin and Coumadin * Decreased sensitivity to some drugs: Beta blocker * Overall prescriber should assume greater sensitivity to drugs.

Answer 166

* 6 or more concurrent chronic conditions * 12 or more doses of drugs/day * 9 or more medications * Prior adverse drug event * low BMI (less than 22) * Age 85 or older * Estimated CrCl < 50 mL/min * History of prior ADE

Answer 167

The key to preventing prescribing cascades lies in the avoidance and early detection of adverse drug reactions and an increased awareness and recognition of the potential for adverse reactions.

Answer 168

The key to preventing prescribing cascades lies in the avoidance and early detection of adverse drug reactions and an increased awareness and recognition of the potential for adverse reactions.

Answer 169

1. Review current drug therapy 2. Discontinue unnecessary therapy 3. Consider adverse drug events for any new symptoms 4. Consider nonpharmacologic approach 5. Start low and go slow 6. Understand effect of drugs in the elderly 7. Reduce the dose 8. Simplify the dosing schedule 9. The fewer drug the better ---Avoid inappropriate polypharmacy ---One drug many use: Use of one drug to address more than one disease. (ARB: HTN and Gout; Remeron: Depression, insomnia, and unintentional weight loss; CCB: HTN and neuroprotective)

Answer 170

Creating an individualized plan 1. Patient life’s expectancy 2. Time till benefit from medication 3. Goal of care 4. Treatment targets 1. Symptom-targeted approach 2. Disease modifying approach Decision-making process based on beneficence and patient’s autonomy.

Answer 171

* consider any new sign and/or symptom in the elderly as a drug side effect until proven otherwise * Principle of slow medicine (see week 1 PPTs) based on beneficence ** START LOW AND GO SLOW** * Try not to start two medications the same time * Search for one medication that might treat two diseases at the same time. * Administration time: Same as the other medication to increase adherence * Use of long acting meds if patient can afford the higher co-pay. * Assess patient and/or care giver knowledge regarding med.

Answer 172

* Uses the correct drug * Prescribes the correct dosage * Targets the correct condition * Is appropriate for the patient Failure in any one of these can result in adverse drug events (ADEs)

Answer 173

STOPP/START criteria The Screening Tool of Older Person's Prescriptions (STOPP) criteria and the Screening tool to alert doctors to right treatment (START) Both screening tools are intended to be used together Help prevent inappropriate polypharmacy and prescribing -> reduction of ADE More thorough than BEERS, as it includes drug-drug interaction, and potential duplications Identify inappropriate prescribing, was introduced in 2008 and updated in 2015 STOPP: Include a list of PIMs (Potentially inappropriate medications) START: Include PPOs (potential prescribing omissions)

Answer 174

What is the AGS Beers Criteria®? The AGS Beers Criteria® includes lists of certain medications worth discussing with health professionals because they may not be the safest or most appropriate options for older adults. Though not an exhaustive catalogue of inappropriate treatments, the five lists included in the AGS Beers Criteria® describe particular medications with evidence suggesting they should be: Avoided by most older people (outside of hospice and palliative care settings); Avoided by older people with specific health conditions; Avoided in combination with other treatments because of the risk for harmful “drug-drug” interactions; Used with caution because of the potential for harmful side effects; or Dosed differently or avoided among people with reduced kidney function, which impacts how the body processes medicine.

Answer 175

1. PIMs to be avoided for all older adults 2. PIMs to be avoided in certain diseases/syndromes 3. PIMs to be used with caution 4. PIMs to be avoided/adjusted in patients with renal disease 5. Drug–drug interactions to be avoided

Answer 176

Informed by extensive evidence review Robust grading methodology Concise Increases awareness of poly pharmacy Aids in the decision making when choosing drugs

Answer 177

1. No RCT evidence of clinical benefit when used as an intervention. 2. Under-prescribing not addressed. 3. Alternative safer drugs not suggested.

Answer 178

Screening Tool of Olders People's Potentially Inappropriate Prescriptions **Prescriptions that are potentially inappropriate in persons aged ≥ 65 years **

Answer 179

START: Screening Tool to Alert doctors to Right (i.e. appropriate, indicated) Treatments. **Treatments that should be considered for people ≥ 65 years of age, where no contraindication exists**

Answer 180

50% of elderly adults of age 65 regularly complain of poor sleep. Patients with medical and psychiatric comorbidities have higher frequencies of insomnia placing our geriatric population at an increased risk. Rates of insomnia in patients with chronic pain and psychiatric disorders range from 50%-75%. Women, regardless of ethnicity, are more likely to suffer from insomnia. Causes of Insomnia are Multifaceted: Predisposing Factors: Aging, female gender, comorbid conditions, vulnerability to insomnia such as anxiety, depression, hyperarousal, and dementia Precipitating Factors: Triggers for insomnia such as a loss of a spouse, retirement, moving to a new home Perpetuating Factors: Maladaptive habits or beliefs that a person has acquired to deal with insomnia such as spending long periods in bed or taking naps Insomnia in older adults is often comorbid with medical and psychiatric illnesses and their symptoms (i.e. restless leg syndrome, sleep apnea, GERD, musculoskeletal illness, drugs) (Buysse et al., 2019)

Answer 181

Diagnostic Tests/Screenings: * Labs to rule out organic disease: CBC with diff, CMP, TSH, A1C, & Vit D (Last labs drawn April 2021) * PHQ-9 Score: 16 (moderate to severe depression); Other screening tools: GDS, BDI, HAM-D, QIDS-SR

Answer 182

Non-Pharmacological Approach: * Cognitive Behavioral Therapy for Insomnia (CBT-1, Stimulus Control, Sleep Restrictive Therapy, Sleep Hygiene

Answer 183

Pharmacological Approach: Trazodone 25 mg q HS Verbal consent for treatment obtained. Taper off Xanax when insomnia, depression, and anxiety controlled. Initiate daily sleep diary and instruct patient to bring to next appointment. Sleep hygiene, identify and eliminate factors contributing to daytime sleepiness.

Answer 184

Patient Education: Set a regular bedtime/wake time every day. Sleep only as much as you need to feel rested, then get out of bed. Avoid caffeine after lunch, and large meals & alcohol near bedtime. Do not smoke (particularly in evening). Get regular exercise during the day, but avoid rigorous exercise within two hours of bedtime. Keep room quiet and dark. Use fan, white noise machine, blackout shades and/or eye mask. Avoid electronics

Answer 185

Follow-Up: Return to office in 2 weeks to follow-up on symptoms, CBT-I, adjust medications if necessary, & reinforce education